What Is the Best Strategy for Brain Protection in Patients Undergoing Aortic Arch Surgery? A Single Center Experience of 636 Patients

Misfeld, Martín; Leontyev, Sergey; Borger, Michael A.; Gindensperger, O; Lehmann, Sven; Légaré, Jean‐François; Mohr, Friedrich W.

doi:10.1016/j.athoracsur.2012.01.106

Cited by 153 publications

(120 citation statements)

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“…In our material, stroke was observed in 11% of patients in the emergency group and 9% in the elective group. This corresponds with the report from Leipzig, in which Misfeld et al [10] observed 11% of neurological incidents. However, in our material acute dissections represented 56% of aortic arch surgeries, while in Leipzig it amounted to 37% [10].…”

Section: Resultsmentioning

confidence: 91%

“…Immer et al [12] showed a significantly better neurological outcome for patients undergoing cerebral perfusion through the right axillary artery compared with selective antegrade perfusion. Over the last few years, the Leipzig group have used routinely axillary access for arch surgery and they have not found any effect of the cannulation site on neurological or other perioperative outcome [10]. Patris et al [13] proved that the femoral artery remains a bailout option in an emergency situation.…”

Section: Resultsmentioning

confidence: 99%

“…DISCUSSION In our material, based on 172 patients operated on due to dissection or true aneurysm of aortic arch between 2007 and 2014, the operative risk estimated by additive EuroSCORE reached a mean value of 10 ± 3. Colleagues from Leipzig (Germany) [10] examined 600 patients who underwent aortic arch surgery in over a seven-year period. The mean operative risk estimated by additive EuroSCORE was 10 ± 3 [10].…”

Section: Resultsmentioning

confidence: 99%

“…Colleagues from Leipzig (Germany) [10] examined 600 patients who underwent aortic arch surgery in over a seven-year period. The mean operative risk estimated by additive EuroSCORE was 10 ± 3 [10]. Additionally, they found that only 37% of their cases were acute type-A dissections, while in our material this number reached 56.4%.…”

Section: Resultsmentioning

confidence: 99%

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Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

et al. 2016

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A b s t r a c tBackground: Surgery of the aortic arch is challenging. Aim:To assess the results of aortic arch surgery. Methods:Analysis of 172 patients operated on arch dissection (emergency group: 97 patients) or aneurysm (elective group: 75 patients) between 2007 and 2014. Arch surgery was defined as a procedure requiring circumferential anastomosis at the level of the aortic arch or the descending aorta with the use of techniques of brain protection (deep hypothermic circulatory arrest [DHCA] or selective antegrade cerebral perfusion [SACP]) and/or debranching of at least one supra-aortic vessel.Results: Men predominated in both groups (> 70%). Men were younger in the emergency group (55 vs. 66 years; p < 0.008). The operative risk was higher in the emergency group (19.2% vs. 12.5%; p < 0.001). Forty-nine per cent of the patients from the emergency group and 5% from the elective group were operated with antiplatelet therapy (p < 0.001). Extended hemiarch procedure was performed in 79% (n = 77) in the emergency and 76% (n = 57) in the elective group. Total arch replacement was performed in 19 (21%) patients from the emergency and 18 (24%) patients from the elective group. In these patients debranching was performed in 68% of the emergency patients group and in 67% of the elective group. Elephant trunk procedure (classic/frozen) was performed in 53% (n = 10) from the emergency and in 78% (n = 14) of patients from the elective group. Aortic valve sparing surgery was performed in 20% of patients from the emergency and 9% from the elective group (p = 0.063). DHCA was performed in 58% (n = 43) of patients from the elective group and 39% (n = 37) from the emergency group. SACP was performed in 61% (n = 58) of patients from the emergency and 42% (n = 31) from the elective group. Thirty-day mortality in the emergency group reached 33% (n = 32), and in the elective group 15% (n = 11; p = 0.007). In multivariate analysis, predictors of death in the emergency group were: Logistic EuroSCORE above 19.5%, extracorporeal circulation time above 228 min, and postoperative acute renal failure (ARF); and in the elective group: DHCA time above 26 min, rethoracotomy due to bleeding, and ARF. Follow-up was completed in 100% of patients in terms of vital status. The mean follow-up time of the patients from the emergency group was 24.3 ± 27.10 (min 0, max 92) months, and from the elective group 30.3 ± 24.5 (min 0, max 99) months. During the follow-up period all-cause mortality in the emergency group was 43% (n = 42/97), and in the elective group it was 36% (n = 27/75). Conclusions:Early mortality in the emergency group was higher, while long-term mortality did not differ among the groups. Postoperative ARF is a critical predictor of mortality in both groups.

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Section: Resultsmentioning

confidence: 91%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

et al. 2016

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“…After retrograde cerebral perfusion was attempted, 53) antegrade cerebral perfusion has recently gained popularity. 54,55) However, status in the skull varies among individual patients, and unexpected malperfusion may occur under artificial perfusion. It should be detected and corrected without delay.…”

Section: Cerebral Malperfusionmentioning

confidence: 99%

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Orihashi¹

2012

Annals of Vascular Diseases

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Despite improved outcomes of acute type A aortic dissection (AAAD), many patients die at the moment of onset, and hospital mortality is still high. This article reviews the latest literature to seek the best possible way to optimize outcomes. Delayed diagnosis is caused by variation in or absence of typical symptoms, especially in patients with neurological symptoms. Misdiagnosis as acute myocardial infarction is another problem. Improved awareness by physicians is needed. On arrival, quick admission to the OR is desirable, followed by assessment with transesophageal echocardiography, and malperfusion already exists or newly develops in the OR; thus, timely diagnosis without delay with multimodality assessment is important. Although endovascular therapy is promising, careful introduction is mandatory so as not to cause complications. While various routes are used for the systemic perfusion, not a single route is perfect, and careful monitoring is essential. Surgical treatment on octogenarians is increasingly performed and produces better outcomes than conservative therapy. Complications are not rare, and consent from the family is essential. Prevention of AAAD is another important issue because more patients die at its onset than in the following treatment. In addition to hereditary diseases, including bicuspid aortic valve disease, the management of blood pressure is important.Keywords: aortic dissection, malperfusion, complication, echocardiography A cute type A aortic dissection (AAAD) not only causes sudden death at the time of onset but leads to various life-threatening complications. In spite of improved diagnostic imaging and surgical strategies, in-hospital mortality is still high, and patients who have survived often suffer from sequelae that make subsequent quality of life poor. This article is aimed to review the latest literature and ideas to seek the best possible way to minimize undesirable results.Various complications of AAAD caused by separation of the aortic wall to outer and inner layers are summarized as three categories: 1) aortic rupture due to disruption of the outer layer; 2) malperfusion caused by the inner layer, that is, the intimal flap; and 3) aortic regurgitation by a deformed aortic valve, leading to acute heart failure. Approximately 20% of patients instantaneously die due to aortic rupture, 1) and 1 to 2% of the remaining patients die every hour unless appropriately treated. 2) Although surgical outcomes are gradually improving, in-hospital mortality of surgical patients (repair on the aortic root to the arch) in 2009 was as high as around 10%, according to the Japanese database. 3) For the further improvement of outcomes, problems should be solved in each of preonset, pre-hospital, and in-hospital stages. In this review, the latter two stages are discussed first, since most of the literature focuses on these stages. After that, the issue of pre-onset stage, i.e., prevention is discussed. DelayeD DiagnosisIn consideration of the natural history of AAAD, the "chain of onset-to-sur...

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Operative Management of My Own Dissection

Carrel

2014

Controversies in Aortic Dissection and Aneurysmal Disease

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What Is the Best Strategy for Brain Protection in Patients Undergoing Aortic Arch Surgery? A Single Center Experience of 636 Patients

Cited by 153 publications

References 20 publications

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

Single-centre experience in surgery of acute aortic type A dissection and true aortic arch aneurysm

Acute Type A Aortic Dissection: for Further Improvement of Outcomes

Operative Management of My Own Dissection

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